Register New User

User Type(s)

Name Type

Government Identifier

Member Identifier/Policy Number

User Type(s)

First/Last Name or Institution Name is required.

First Name

Last Name

Or

Provider Group / Institution Name

National Provider ID or Provider Government ID is required.

National Provider ID

Or

Provider Government ID

Payee Address

For Individual Providers, enter a valid NPI or Government ID (or both).
For Group/Institution Providers, enter Name and a valid NPI or Government ID (or both).

User Type(s)

First Name

Last Name

Email Address (example: jsmith@abc.com)

Phone Number

Job Title

Company Authorization

User Type(s)

First Name

Last Name

Date of Birth(mm/dd/yyyy):

Government Identifier

Agent Number

User Type(s)

Agency Name

Government Identifier

Agency Number

User Type(s)

First Name

Last Name

Email Address (example: jsmith@abc.com)

Phone Number

Job Title

Company Authorization

GP_Registration